Laserfiche WebLink
`Ir <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r Slate of California <br /> callfomla integrantdiWase Management Board Survey Form - Page 1 17 - 1013618 <br /> Part A-S_urvey ._ _ _ BLUE OR BLACK INK PEN <br /> Business Profile _ Inspection Details <br /> TPID- Z 2 _ 7 - O Inspection Type (Fill one) <br /> Site Suffix: J J 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Cd/L +H .� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address - / Q / s'i4 <br /> I fl'�/i F-v✓? <br /> Inspection Date (0 <br /> Time In Time Out <br /> Business Rep Title / *AM AM <br /> Q PM / O O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholelPTE) p (Fill one only) (Fill all that apply)i (Fill all that apply) (Fill.all that apply) <br /> O 0 Active IS Passenger 1 ®Generator Q Outdoor <br /> Latitude 0 Q Closed Q Altered <br /> GPS Q Hauler 0 Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB 3s , <br /> s <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs Within 90 days , <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years 7� . <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities s � .xfi-;�:���•.r :� �. _ <br /> O O <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § < y <br /> Comments Ase,eI 4 >4rrxy <br /> �IY'� klcf'C ��Gre. +�_�'Q.k�� %:r� �' 7�s�.rr-�"e+w► �.i'<. � �/'e <br /> tea,., 9��e /�e.l �r4� �-� �u•ouie� �-tee.., 1�e �i'�C u&-P 2 � <br /> 1t� �� �e eatc�. �yu�;' cb o•� �. <br /> Inspection Form Included: <br /> Comments Included:QQ � L' Q//J W/V � Y'07 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK E X a P L i 62081 <br /> AA <br /> White Copy CIWMB Yellow Capt'Operator Pink Copy.LEA <br /> 0611904.0407f <br />